Chapter 7: Keeping Promises

Introduction

Keeping promises reduces uncertainty and promotes trust. Physicians, like all people, make promises and are sometimes tempted to break them. Although promises are regarded as binding, in retrospect, some promises might seem imprudent or mistaken. The following cases demonstrate that some promises can be kept only if important ethical guidelines are violated.


Case 7.1. Promise not to tell the patient that she has cancer

Mrs. G, a 61-year-old Mexican American widow, is found to have cancer on a needle aspiration of a breast mass. Her primary care physicians agrees to a request from her daughter and son to tell her she has cancer because they fear that she would not be able to handle the bad news. They point out that it is not customary in Mexico to tell women of her age that they have cancer. After breast cancer is diagnosed, the physician refers Mrs. G to a surgeon.

The surgeon believes that patients need to be involved in decisions regarding mastectomy or lumpectomy. In addition, Mrs. G asks a Spanish-speaking nurse, “Why do I need surgery? Do I have cancer?” The nurse does not want to deceive a patient who asks a direct question. The surgeon and nurse feel constrained by the primary physician’s promise not to tell Mrs. G her diagnosis.

When Mrs. G’s children asked that she not be told she has cancer, the primary care physician should elicit the concerns underlying their request. The doctor should anticipate future problems if she is not told, including the possibilities that other health care workers may decide to disclose the diagnosis or the patient may ask someone directly what her diagnosis is.

Another health care worker, like the surgeon in this case, may decide that she cannot provide care without offering to discuss Mrs. G’s diagnosis with her. In her view, avoiding deception should prevail over keeping a promise made by a third party. Similarly, when asked by the patient if she has cancer, it would be disrespectful to deceive her rather than giving a direct and compassionate answer.


Case 7.1 illustrates that in some situations, keeping promises might be problematic. The surgeon and nurse believe that the primary physician’s promise not to tell Mrs. G her diagnosis fails to respect her as a person. They question why they should violate their sense of moral integrity to keep someone else’s promise.


Case 7.2. Promise to schedule tests

Mr. H, a 54-year-old heavy smoker, is hospitalized for hemoptysis, weight loss, and angina pectoris. A chest x-ray shows a 2-cm proximal lung mass, with hilar adenopathy. A bronchoscopy is scheduled to obtain a biopsy. When the intern walks by his room, the patient shouts, “This is outrageous. I haven’t had breakfast, I haven’t had lunch. Now they say they don’t know when the test will be done and that I might have to go through all this again tomorrow.

If this is how the hospital is run, I’m leaving.” The intern, eager to appease the patient and continue with his other work, promises the patient that the test will be done that afternoon. He tells the nurse to call the bronchoscopy suite to say that the procedure needs to be done that afternoon.

Physicians should not make promises about situations they cannot control. In the short run, it might seem easier to promise that the test will be done rather than to have the patient complain. However, making a promise that may not be kept will cause more problems in the long run. It might be better simply to listen and acknowledge that the patient has every right to be angry. Realistically, the doctor can promise to look into the matter and to do his best to get the procedure done as soon as possible, for instance, phoning the pulmonary consultant.


In Case 7.2, the intern makes a promise so Mr. H will cooperate with getting a needed test. However, the bronchoscopy schedule is not under his control. Even though the intern’s motive is beneficent—to help the patient receive needed medical care—the means of achieving his goal is ethically problematic.

The Ethical Significance of Promises

A promise is a commitment to act a certain way in the future, either to do something or to refrain from doing something. Promises generate expectations in others, who, in turn, modify their plans and actions on the assumption that promises will be kept [1]. In everyday social interactions, people expect others to keep the ones they make. Promises might be exchanged for other promises, as in a business contract. For example, a merchant might promise to deliver goods in exchange for the promise of payment on delivery.

Keeping promises is desirable for several reasons. It results in beneficial consequences by making the future more predictable, relieving anxiety, and promoting trust. Indeed, the dictionary definition of “promise” is “that which causes hope, expectation, or assurance.” Keeping promises is also important even if there are no short-term beneficial consequences. Promise-keeping is essential for harmonious social interactions. If promises are commonly broken, then people would be unwilling to rely on others to keep commitments.

Breaking promises may cause significant harm. The person to whom the promise was made may suffer a setback, such as inconvenience and monetary losses. It seems unfair to allow people to break promises that others have relied on [2]. The very concept of promises is negated if people break them and gain an advantage but expect others to honor promises [2].

Promise-keeping is especially important for physicians. Because the doctor–patient relationship is based on trust, patients might feel betrayed if physicians break promises. Once betrayed, patients might be less likely to trust the individual physician or the medical profession. Promises by physicians might help patients cope with the uncertainty and fears inherent in being sick.

In addition, promises establish mutual expectations that benefit both physicians and patients. For example, physicians promise confidentiality of medical information; in return, patients are more candid about discussing sensitive issues pertaining to their health. Thus, promises enhance the patient’s well-being and facilitate the physician’s work.

Problems with Keeping Promises

None of us wants to keep all the promises we make. Some promises are made on the spur of the moment, under emotional stress, with inadequate information, or without proper deliberation [2]. Foolish promises that put one at a great disadvantage are often retracted, particularly if they confer a gratuitous boon on the other person. People might excuse breaking such promises if the other person has taken no action in reliance on the promise and is no worse off than if the promise had never been made.

Clinical dilemmas occur when keeping promises would require actions that violate other ethical guidelines. In Case 7.1, the surgeon and nurse believe the initial promise not to tell the patient violates the guideline of respect for persons.

Suggestions for Physicians

Do Not Make Promises Lightly

A statement that the physician regards as kindly reassurance might be interpreted by the patient or family as a promise. Even if the physician does not think a promise is important, the patient may. Patients typically are more upset when physicians break promises than the physicians are.

Address the Concerns Underlying the Request for a Promise

If someone asks the physician to make an unrealistic promise, then the physician can elicit the underlying concerns and try to address them in other ways.

Do Not Promise Outcomes That Are Out of Your Control

Physicians should not make promises that are beyond their power to keep. Given the complex organization of modern medicine, it is misleading to make promises about other physicians and nurses, who are autonomous agents with their own moral and professional values.

Because clinical outcomes are inherently uncertain, it is unrealistic to make a promise that guarantees a good outcome or the absence of complications after a procedure.

Do Not Violate Ethical Guidelines Because of an Ill-Considered Promise

Although promise-keeping is important, it is not an absolute duty. Other ethical guidelines are also important and might take priority in some situations. In some cases, breaking the promise might be the lesser of two evils. The strongest case for overriding the promise-keeping occurs when the following conditions are met:

  • Keeping the promise would violate another important ethical guideline. In Case 7.1, keeping the promise would require deception by the physician and, thereby, compromise the patient’s autonomy.
  • The countervailing ethical considerations were not taken into account when the promise was made.
  • The clinical and ethical situation has changed significantly since the promise was made.
  • Someone else made the promise. Although a person’s promise can bind his own future actions, it need not bind others.
  • The promise was stated implicitly rather than explicitly.

In summary, promises can allay patients’ fears and uncertainty. It is important to keep promises because other people rely on them. Breaking promises undermines trust in the individual physician and in the medical profession, yet keeping promises is not an absolute ethical duty. Sometimes, respecting a promise might require the physician to violate other important ethical guidelines. In exceptional situations, breaking a promise might be justified as the lesser of two evils.

Summary

  1. Physicians should keep promises because other people rely on them.
  2. In exceptional circumstances, breaking a promise might be justified as the lesser of two evils.